title: Management of ruptured intracranial aneurysms in the post-ISAT era: outcome of surgical clipping versus endovascular coiling in a Singapore tertiary institution.
abstract: BACKGROUND
  The results of the International Subarachnoid Aneurysm Trial (ISAT) in 2002 have significantly influenced the management of ruptured intracranial aneurysms. There is now an established shift worldwide toward endovascular coiling as the initial treatment of choice. We assessed the outcomes of patients admitted to our institution for aneurysmal subarachnoid haemorrhage (SAH), comparing the outcomes of patients (World Federation of Neurosurgical Societies [WFNS] grades 1-3) who underwent surgical clipping versus those who underwent endovascular coiling.
  
  
  METHODS
  We retrospectively reviewed patients admitted to the National University Hospital for SAH secondary to ruptured intracranial aneurysm in 2005-2009. Patients were divided into two groups - clipping and coiling. Data on individual demographics, comorbidities, Fisher grading and Glasgow Outcome Scale scores were collected for the two groups and subjected to relevant statistical analyses.
  
  
  RESULTS
  Of the 133 patients admitted for nontraumatic SAH, 89 had ruptured aneurysms. Among the 56 patients classified as WFNS grades 1-3, 23 underwent coiling while the remaining 33 underwent clipping. A significant association was found between Fisher grade and the likelihood of developing hydrocephalus in these patients.
  
  
  CONCLUSIONS
  Although we acknowledge the presence of management bias in our institution, our findings were similar to those of the ISAT trial. Upon correlation between our results and current evidence-based findings, our findings show that clipping provides similar long-term outcomes as endovascular coiling. In the event that an aneurysm is deemed unsuitable for coiling, clipping remains an effective option.
authors.affiliation: Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433. sharon.yy.low@gmail.com
authors.forename: K M
authors.initials: KM
authors.lastname: Koh
authors.forename: Z
authors.initials: Z
authors.lastname: Ng
authors.forename: S Y
authors.initials: SY
authors.lastname: Low
authors.forename: H Z
authors.initials: HZ
authors.lastname: Chua
authors.forename: N
authors.initials: N
authors.lastname: Chou
authors.forename: S W
authors.initials: SW
authors.lastname: Low
authors.forename: T T
authors.initials: TT
authors.lastname: Yeo
mesh_terms: D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000601:surgery* / Q000628:therapy*; D015901:Angiography, Digital Subtraction / Q000379:methods; D015897:Comorbidity; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D023261:Glasgow Outcome Scale; D006470:Hemorrhage; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009493:Neurosurgery / Q000379:methods*; D019635:Neurosurgical Procedures / Q000379:methods; D012189:Retrospective Studies; D012846:Singapore; D013345:Subarachnoid Hemorrhage / Q000601:surgery*; D016896:Treatment Outcome